US8419727B2

US8419727B2 - Impedance mediated power delivery for electrosurgery

Info

Publication number: US8419727B2
Application number: US12/748,229
Authority: US
Inventors: Tim Koss; Miriam H. Taimisto; Roseanne Varner
Original assignee: Aesculap AG
Current assignee: Aesculap AG
Priority date: 2010-03-26
Filing date: 2010-03-26
Publication date: 2013-04-16
Also published as: US20130116678A1; US9277962B2; US20110238062A1

Abstract

An adaptive algorithm monitors the rate of tissue impedance change during an electrosurgical procedure. Impedance levels are examined to determine an impedance ramp and/or slope rate, which indicates the rate at which a target tissue is undergoing a phase or state change. The level of electrosurgical energy applied to the target tissue is adjusted in real time. Energy is applied to the target tissue at levels that allow tissue phase or state change to occur in an optimum fashion. Undesired results such as thermal damage and defective sealing are mitigated. Another embodiment determines impedance achieved within a specific interval and adjusts the electrosurgical energy applied to the tissue after a threshold impedance has been maintained or exceeded for a predetermined interval. A further aspect of the invention provides mitigation during processing for partial tissue coverage of device electrodes or thin tissue.

Description

BACKGROUND OF THE INVENTION

1. Technical Field

The invention relates to electrosurgery. More particularly, the invention relates to impedance mediated power delivery for electrosurgery.

2. Description of the Prior Art

The state of the art of electrosurgery is well summarized in U.S. patent publication no. 2009/0157071 (Wham et al), where it is stated:

“Electrosurgery involves application of high radio frequency electrical current to a surgical site to cut, ablate, or coagulate tissue. In monopolar electrosurgery, a source or active electrode delivers radio frequency energy from the electrosurgical generator to the tissue and a return electrode (e.g., a return pad) carries the current back to the generator. In monopolar electrosurgery, the source electrode is typically part of the surgical instrument held by the surgeon and applied to the tissue to be treated. The patient return electrode is placed remotely from the active electrode to carry the current back to the generator.

In bipolar electrosurgery, one of the electrodes of the hand-held instrument functions as the active electrode and the other as the return electrode. The return electrode is placed in close proximity to the active electrode such that an electrical circuit is formed between the two electrodes (e.g., electrosurgical forceps). In this manner, the applied electrical current is limited to the body tissue positioned between the electrodes. When the electrodes are sufficiently separated from one another, the electrical circuit is open and thus inadvertent contact of body tissue with either of the separated electrodes does not cause current to flow.

Bipolar electrosurgery generally involves the use of forceps. A forceps is a pliers-like instrument which relies on mechanical action between its jaws to grasp, clamp and constrict vessels or tissue. So-called “open forceps” are commonly used in open surgical procedures whereas “endoscopic forceps” or “laparoscopic forceps” are, as the name implies, used for less invasive endoscopic surgical procedures. Electrosurgical forceps (open or endoscopic) utilize mechanical clamping action and electrical energy to effect hemostasis on the clamped tissue. The forceps include electrosurgical conductive plates which apply the electrosurgical energy to the clamped tissue. By controlling the intensity, frequency and duration of the electrosurgical energy applied through the conductive plates to the tissue, the surgeon can coagulate, cauterize and/or seal tissue.

Tissue or vessel sealing is a process of liquefying collagen, elastin and ground substances in tissue so that they reform into a fused mass with significantly-reduced demarcation between opposing tissue structures. Cauterization involves the use of heat to destroy tissue and coagulation is a process of desiccating tissue wherein the tissue cells are ruptured and dried.

Tissue sealing procedures involve more than simply cauterizing or coagulating tissue to create an effective seal; the procedures involve precise control of a variety of factors. For example, in order to affect a proper seal in vessels or tissue, it has been determined that two predominant mechanical parameters must be accurately controlled: the pressure applied to the tissue; and the gap distance between the electrodes (i.e., distance between opposing jaw members or opposing sealing plates). In addition, electrosurgical energy must be applied to the tissue under controlled conditions to ensure creation of an effective vessel seal. Techniques have been developed whereby the energy applied to the tissue is varied during the tissue sealing process to achieve a desired tissue impedance trajectory. When a target tissue impedance threshold is reached, the tissue seal is deemed completed and the delivery of electrosurgical energy is halted.”

Wham et al takes the approach of incorporating a cooling period subsequent to a tissue reaction that occurs after the application of electrosurgical energy to the tissue, where such electrosurgical energy is applied to the tissue in accordance with an algorithm that reduces power with increasing tissue impedance (see Wham et al, FIG. 8). However, this approach merely adjusts the amount of electrosurgical energy applied as it tracks tissue impedance vis a vis a target tissue impedance. The approach does not take in to account the actual change of state within the tissue and thus does not address such issues as thermal damage to the tissue and defective sealing.

SUMMARY OF THE INVENTION

An embodiment of the invention provides an electrosurgical technique that addresses such issues as thermal damage to the tissue, partial coverage of the electrodes of the electrosurgical device by tissue, thin tissue, and defective sealing. This improvement is accomplished by use of an adaptive algorithm that monitors, inter alia, the rate of tissue impedance change. An aspect of the invention thus examines impedance levels achieved within a specific timeframe to determine an impedance ramp and/or slope rate, which indicates the rate at which the target tissue is undergoing a phase or state change and, thus, indicates tissue processing. The level of electrosurgical energy applied to the target tissue is adjusted in real time in accordance with such rate of impedance change. This approach, in effect, applies the energy at levels that allow tissue phase or state change to occur in an optimum fashion, for example allowing moisture to escape from the tissue slowly, and thus avoid thermal damage. As a result, such undesired results as thermal damage and defective sealing are mitigated.

Another embodiment of the invention determines impedance achieved within a specific interval and adjusts the electrosurgical energy applied to the tissue after a threshold impedance has been maintained or exceeded for a predetermined interval.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 is a block schematic diagram of an apparatus for impedance mediated power delivery for microsurgery according to the invention;

FIG. 2 is a flow diagram showing an algorithm for impedance mediated power delivery for microsurgery according to a first embodiment of the invention;

FIG. 3 is a flow diagram showing an algorithm for impedance mediated power delivery for microsurgery according to a second embodiment of the invention;

FIG. 4 is a timing diagram showing an impedance mediated power delivery ramp for microsurgery according to the invention;

FIG. 5 is a timing diagram showing an impedance mediated power delivery interval for microsurgery according to the invention;

FIG. 6 is a timing diagram showing a modified power delivery profile according to the invention;

FIG. 7 is a timing diagram showing an endpoint detection profile according to the invention; and

FIG. 8 is a timing diagram showing a partial tissue coverage mitigation profile according to the invention.

DETAILED DESCRIPTION OF THE INVENTION

An embodiment of the invention provides an electrosurgical technique that addresses such issues as thermal damage to the tissue, partial coverage of the electrodes of the electrosurgical device by tissue, thin tissue, and defective sealing. This improvement is accomplished by use of an adaptive algorithm that monitors, inter alia, the rate of tissue impedance change. An aspect of the invention thus examines impedance levels achieved within a specific timeframe to determine an impedance ramp and/or slope rate, which indicates the rate at which the target tissue is undergoing a phase or state change and, thus, indicates a desired rate of tissue processing. The level of electrosurgical energy applied to the target tissue is adjusted in real time in accordance with such rate of impedance change and/or impedance thresholds reached. This approach, in effect, applies the energy at levels that allow tissue phase or state change to occur in an optimum fashion, for example allowing moisture to escape from the tissue slowly avoiding thermal damage and/or reducing energy for thin tissue or partially covered electrodes. As a result, such undesired results as thermal damage and defective sealing are mitigated.

Another embodiment of the invention determines impedance achieved within a specific interval and adjusts the electrosurgical energy applied to the tissue after a threshold impedance has been exceeded for a predetermined interval. This approach, in effect, determines when the tissue phase or state change has successfully occurred and that the application of energy can be halted.

FIG. 1 is a block schematic diagram of an apparatus for impedance mediated power delivery for microsurgery according to the invention. In FIG. 1, an individual is shown undergoing a procedure in which electrosurgery is being performed on the individual's tissue 10 by an electrosurgical appliance 12, as is known in the art. A source of energy, such as an RF generator 18 is coupled to the electrosurgical appliance by a control circuit 16. The control circuit is operable to adjust any of the current and voltage output and, in some embodiments, adjust the phase relation between the voltage and current, from the RF generator and, thus, to adjust the power output of the RF generator. The control circuit can adjust the RF generator output up and/or down in steps and/or in a selected ramp and/or slope.

The effect of the electrosurgical appliance on the tissue is monitored at the site of tissue treatment by one or more sensors within or proximate to the electrosurgical appliance. A signal produced by the one or more sensors is coupled to a sensor circuit 14. The sensors can monitor such factors as temperature, impedance, RF voltage, RF current, and the like. In the preferred embodiment, the sensor monitors the components of impedance and RF power.

The sensor circuit generates an output signal that is coupled to a processor 15. The processor operates under control of a program and adjusts the output of the RF generator by issuing control signals to the control circuit. In doing so, the processor applies the signal provided by the sensor circuit to the program and adjusts the RF power supplied to the tissue, for example, in real time in response to signal generation by the sensors. Thus, in some embodiments of the invention the process of treating the tissue is monitored in real time and the effect of the treatment upon the tissue, as indicated by the sensors, is used to mediate the application of energy to the tissue. The program may be retained in a memory 17 and includes both instructions for operating the processor and parameters that determine how to respond to signals from the sensor, timing information, and the like.

An important feature of the invention is the manner in which the processor operates the control circuit and, thus, the manner in which energy is supplied to the tissue, in response to signals provided to the processor from the one or more sensors via the sensor circuit. In a preferred embodiment, the one or more sensors monitor the impedance of the tissue. As the tissue is processed by application of energy thereto, a phase or state change gradually occurs and this phase or state change results in a change in the impedance of the tissue. It is known in the art to monitor tissue impedance in connection with such treatments. Uniquely, an embodiment of the invention provides an adaptive power ramp and/or slope by which a lower level of energy is initially supplied to the tissue. The output of the RF generator supplied to the tissue is gradually increased to a higher level of energy and/or the rate of power output is increased or decreased. This ramp and/or slope is provided for a predetermined interval. In some embodiments, during the interval, the impedance of the tissue is monitored in real time and the change in impedance over time and/or threshold achieved is used to determine the slope or rate of a next ramp. The change in impedance is thought to indicate the rate at which tissue phase or state change is progressing. If the rate of such change occurs too quickly, the tissue may be degraded as a result of thermal damage, for example where moisture in the tissue escapes too quickly or forcefully in the form of steam. Thus, key to the invention is a recognition that the rate of change of impedance tracks the rate of phase or state change of the tissue. The processor is programmed to adjust the energy ramp and/or slope during each interval of energy application based upon this rate of change in impedance over time and/or by impedance thresholds achieved. It should be appreciated that, for purpose of the discussion herein, the ramp of energy output refers to the difference between the output level at the start of the ramp and the output level achieved at the end of the ramp, while the slope refers to the rate at which the energy output is increased over time.

One aspect of the invention allows a determination to be made if the electrosurgical appliance electrodes are partially covered by the tissue that is being treated, or if the tissue that is being treated is relatively thin, such as 0.5 mm or less. If the electrodes are partially covered by the tissue or if thinner tissue is being treated, the rate of change of impedance is greater because less tissue is being treated. Accordingly, the energy supplied or the interval over which energy is supplied can be adjusted. For example, in some embodiments, if the partial coverage of tissue or if thinner tissue is being treated, the energy ramp and/or slope is more gradual, whereas if the tissue is thick, then the rate of change of impedance is lesser, and the energy ramp and/or slope is steeper. Other embodiments adjust the power level and/or interval over which power is delivered to the tissue in accordance with, for example, rate of change of tissue impedance. In this way, the invention applies the rate of change in impedance and/or threshold levels achieved, to mediate energy supplied to the tissue.

In an alternate or supplemental embodiment, a target tissue impedance is established, based upon criteria stored in the memory and, once that impedance is reached, energy continues to be supplied for a predetermined interval. That is, a target tissue impedance is achieved and energy is supplied to the tissue for a period of time after the impedance is reached. This embodiment of the invention determines a preferred tissue impedance for processing and then continues supplying energy to the tissue once this impedance is reached. This is accomplished by a ramp and/or slope mechanism similar to that described above, where a measure of sustained energy is maintained at a particular impedance. When a certain time has elapsed at this threshold impedance, tissue processing is considered complete.

The two embodiments of the invention may be used alone or in combination. For example, the rate of change in impedance may be used to determine when sufficient tissue processing has occurred, that is when a threshold impedance is reached; and the threshold impedance may then be used to continue processing until the tissue is completely transformed. In this way, the tissue is processed at a rate that avoids thermal damage and defective sealing, and the tissue is processed sufficiently to complete phase or state change.

FIG. 2 is a flow diagram showing an algorithm for impedance mediated power delivery for microsurgery according to a first embodiment of the invention. In FIG. 2, energy is applied to the tissue at an initial level (200) to begin tissue processing in a gentle fashion. The energy level is ramped to a full energy level (210) in accordance with a ramp and slope that is established as a function of rate of change of impedance (220). If a threshold impedance is reached and maintained or exceeded over a predetermined amount of time, indicating that the tissue is fully processed (230), the process is complete (250) and energy is no longer supplied to the tissue. Else, the energy ramp is adjusted based upon the tissue impedance and the rate of change in the tissue impedance (240) and the process continues.

FIG. 3 is a flow diagram showing an algorithm for impedance mediated power delivery for microsurgery according to a second embodiment of the invention. In FIG. 3, energy is applied to the tissue (300) and the tissue impedance is measured (310). If the threshold impedance is achieved, e.g. 250 Ohms (320), then energy is applied to the tissue for a predetermined, cumulative interval t, e.g. 1.5 seconds. At the end of this interval, tissue processing in complete (340). If the threshold impedance is not achieved, the tissue impedance is monitored as energy is applied to the tissue (330) and the process continues. Further, if thin tissue or partial tissue coverage is detected (350), then the energy level is reduced, e.g. voltage is reduced by 75% (350), and the process then continues as outlined above.

As discussed above, both techniques may be combined. For example, the application of energy in the embodiment of FIG. 3 may be in accordance with a ramp and/or slope that is determined as a function of the rate of change of the tissue impedance and/or an impedance threshold achieved. Likewise, the interval of energy application to the tissue in the embodiment of FIG. 2 may be in accordance with the determination of a threshold impedance, that is the ramp may be eliminated once the threshold impedance is achieved, at which point energy is supplied to the tissue at a higher level.

FIG. 4 is a timing diagram showing an impedance mediated power delivery ramp for microsurgery according to the invention. In FIG. 4, a first ramp 40 is shown over an interval of three seconds. For purpose of this embodiment of the invention, the ramp interval is three seconds and the same interval is used for each ramp. Those skilled in the art will appreciate that other intervals may be used and that the intervals themselves may be varied as a result of the rate of impedance change.

It can be seen that the slope of the first ramp interval includes a first, steep portion, a shallow middle portion, and a relatively flat third portion. Thereafter, the energy is reduced and the next ramp is commenced. In this embodiment, each ramp is mediated in real time in view of the rate of change of tissue impedance, and can also include the absolute impedance (as in the embodiment of FIG. 3) as well. The slope of the second ramp 42 includes less of a steep, initial portion; the slope of the third ramp 44 has a less pronounced slope; the slope of the fourth ramp 46 has an even shallower slope. The area under each ramp indicates the total energy supplied to the tissue during the ramp. In the preferred embodiment, as the tissue is processed and less moisture is retained in the tissue, the energy can be applied at a greater rate, thus reducing sealing time. Thus, as the tissue is processed in this embodiment, more energy is supplied to the tissue, i.e. the ramp is increased, and the energy is supplied more quickly, i.e. the slope is increased. In other embodiments, either or both of the slope and ramp may be increased or decreased at the same time; one of the slope or ramp may be held constant, while the other of the slope or ramp is increased or decreased; one of the slope or ramp may be increased, while the other of the slope or ramp is increased; or the relative increase and/or decrease of the slope and/or ramp may be altered over time, all in accordance with the rate of phase or state change in the tissue. In this way, the rate of phase or state change in the tissue, as indicated by the rate of change of tissue impedance, is used to mediate the delivery of energy to the tissue.

FIG. 5 is a timing diagram showing an impedance mediated power delivery interval for microsurgery according to the invention. In FIG. 5, an initial energy ramp 50 is supplied to the tissue. A subsequent ramp need not be provided in this embodiment. Once the desired impedance is reached, the energy supplied to the tissue 52/54 is maintained at a desired level for a predetermined interval of time.

EXAMPLES

Modified Power Delivery (Mitigation for Thermal Spread)

RF energy is delivered to the target tissue in multiple pulses of energy. The length of each pulse is defined as the RF Pulse Duration and the maximum number of pulses allowed for each seal is defined as the Max. RF Pulse Count. See FIG. 6.

Method:

1. The first RF pulse for a seal starts at a power level defined as the RF Setpoint Start Value. See FIG. 6.

2. The RF power level is then increased from the RF Setpoint Start Value by a rate defined as the RF Setpoint Ramp and/or slope rate until the power level reaches the upper level defined as the RF Setpoint End Value. The RE power level remains at this value until the end of the pulse time is reached. See FIG. 6.

3. At the end of each pulse, the tissue impedance value is calculated and recorded as the RF Pulse End Impedance and the power levels are then set to zero. See FIGS. 6 and 7.

4. For all pulses subsequent to the first, the following evaluations are made. See FIGS. 6 and 7:

- If the RF Pulse End Impedance is less than a threshold defined as RF Setpoint Ramp Impedance Threshold, the RF power delivered is ramped identical to the first pulse.
- If the RF Pulse End Impedance is greater than the RF Setpoint Ramp Impedance Threshold, the RF power delivered is not ramped but stepped directly to the RF Setpoint End Value.

TABLE 1

Typical Values and Ranges - Modified Power Delivery

Value	Typical	Range

RF Pulse Duration	3.0	sec.	0.5-10.0	sec.
Max. RF Pulse Count	5	pulses	1-30	pulses
RF Setpoint Start Value	50	watts	25-150	watt
RF Setpoint Ramp and/or	50	watt/sec.	1-100	watt/sec.
slope rate
RF Setpoint End Value	150	watts	50-150	watt

RF Pulse End Impedance	based on tissue	2-900	ohms
	response

RF Setpoint Ramp	50	ohms	5-250	ohms
Impedance Threshold

Endpoint Detection

The sealing cycle is terminated when the tissue impedance reaches a predetermined threshold for a specified length of time OR when a fault or error condition is detected. A successful sealing cycle is defined here.

Method:

1. The tissue impedance is calculated using the signals from the RF monitoring hardware circuits.

2. When the calculated tissue impedance exceeds a threshold level defined as the Impedance Endpoint Threshold, a timer is started. If the calculated tissue impedance falls below the Impedance Endpoint Threshold, the timer is halted. See FIG. 7.

3. If the above timer accumulates a value defined as the Seal Endpoint Time, the RF delivery is halted, the user is notified of the completed seal and the system is placed in the Ready state. See FIG. 7.

TABLE 2

Typical Values and Ranges - Endpoint Detection

Value		Typical	Range

Impedance Endpoint Threshold	250	ohms	100-750	ohms
Seal Endpoint Time	1.5	sec.	0.1-5.0	secs.

Partial Coverage Mitigation

The exemplary RF generator should seal tissue that is fully covered by the RF electrodes, as well as smaller tissue that is partially covered by the RF electrodes. Partially covered electrodes can create a challenge to RF delivery due to the increased rate at which the tissue desiccates. The following describes the mitigation incorporated in the RF delivery algorithm to address this issue.

Method:

2. When the calculated tissue impedance exceeds a threshold level defined as the Impedance Cutback Threshold for a duration defined as the Impedance Cutback Time, the RF delivery is reduced by decreasing the RF Voltage being delivered. See FIG. 8.

3. The RF Voltage is reduced by a value defined as RF Voltage Cutback.

4. If the tissue impedance exceeds the Impedance Cutback Threshold a second time, the RF Voltage is reduced again by the value of the RF Voltage Cutback.

TABLE 3

Typical Values and Ranges - Partial coverage Mitigation

	Value		Typical	Range

Impedance Cutback Threshold	700	ohms	100-900	ohms
Impedance Cutback Time	0.1	sec.	0.01-2.0	secs.
RF Voltage Cutback	35	volts	1-100	volts

Although the invention is described herein with reference to the preferred embodiment, one skilled in the art will readily appreciate that other applications may be substituted for those set forth herein without departing from the spirit and scope of the present invention. Accordingly, the invention should only be limited by the Claims included below.

Claims

The invention claimed is:

1. An electrosurgery method, comprising the steps of:

applying energy to an individual's tissue with an electrosurgical appliance that comprises a plurality of electrosurgical appliance electrodes;

monitoring rate of tissue impedance change;

generating a signal indicative of said rate of tissue impedance change;

providing a processor configured to determine an impedance ramp and/or slope rate from said signal, said impedance ramp and/or slope rate indicates a rate at which said individual's tissue is undergoing a phase or state change;

said processor configured to continuously adjust a ramp and/or slope of energy applied to said individual's tissue via said electrosurgical appliance in real time, and to adjust a rate at which an ultimate level of energy is achieved while applying energy to said individual's tissue in accordance with said impedance ramp and/or slope rate; and

continuing to monitor said rate of tissue impedance change and to adjust said level of energy applied to said individual's tissue until tissue processing is complete;

wherein energy is applied to said individual's tissue at levels that allow tissue phase or state change to occur in an optimum fashion,

wherein a first radiofrequency, RF, pulse for a seal starts at a power level defined as start value,

the RF power level is then increased from the start value until the power level reaches an upper level and the RF power level remains at this upper level until the end of the pulse time is reached,

at the end of each pulse, the tissue impedance value is calculated and recorded as an RF Pulse End Impedance, and the power levels are then set to zero,

for all pulses subsequent to the first, the following evaluations are made,

if the RF Pulse End Impedance is less than a threshold, the RF power delivered is ramped similar to the first pulse, and

if the RF Pulse End Impedance is greater than said threshold, the RF power delivered is not ramped but stepped directly to said upper level.

2. The method of claim 1, further comprising the step of:

applying energy to said individual's tissue at an initial energy level and increasing said energy level to a terminal energy level.

3. The method of claim 2, further comprising the step of:

increasing said energy level from said initial energy level to said terminal energy level in any of a series of discrete steps or in a continuous fashion over time.

4. The method of claim 1, further comprising the steps of:

monitoring tissue impedance;

generating a signal indicative of said tissue impedance;

providing a processor configured to determine when a threshold impedance is reached within a specific interval;

said processor configured to apply a constant, predetermined level of energy to said individual's tissue after said threshold impedance is reached and to continue application of said constant, predetermined level of energy to said individual's tissue for a predetermined interval; and

said processor configured to discontinue application of energy to said individual's tissue after completion of said predetermined interval.

5. The method of claim 1, further comprising the step of:

providing a processor configured to determine if said electrosurgical appliance electrodes are partially covered by the individual's tissue or are covered by thin tissue by determining if a rate of change and/or impedance threshold is reached, and thereafter applying a decreasing ramp rate and/or power cutback to prevent over-processing of the tissue.

6. An electrosurgery method, comprising the steps of:

applying energy to an individual's tissue with an electrosurgical appliance;

monitoring tissue impedance;

generating a signal indicative of said tissue impedance;

said processor configured to discontinue application of energy to said individual's tissue after completion of said predetermined interval,

wherein an impedance mediated power delivery ramp for microsurgery is provided,

a slope of said power delivery ramp of a first ramp interval including a first, steep portion, a shallow middle portion, and a relatively flat third portion,

whereafter, the energy is reduced and a second ramp is commenced wherein each ramp is mediated in real time in view of the rate of change of tissue impedance,

the slope of said second ramp includes less of a steep, initial portion,

wherein, as the tissue is processed, more energy is supplied to the tissue, i.e. the ramp is increased.

7. The method of claim 6, wherein said step of providing a processor configured to determine when a threshold impedance is reached within a specific interval comprises the step of providing a processor configured to:

determine when each of a plurality of threshold impedances is reached within a corresponding specific interval; and

discontinue application of energy to said individual's tissue after completion of a last of said corresponding predetermined intervals.

8. An electrosurgery apparatus, comprising:

an electrosurgical appliance for performing electrosurgery on an individual's tissue;

a source of energy coupled to the electrosurgical appliance by a control circuit, said control circuit configured to adjust any of the current and voltage output from said source of energy and, thus, to adjust power output of said source of energy, said control circuit configured to adjust said power output of said source of energy up and/or down in steps and/or in a selected ramp;

a sensor within or proximate to said electrosurgical appliance for monitoring an effect of said electrosurgical appliance on said individual's tissue and producing a tissue impedance signal therefrom;

a processor coupled to receive said tissue impedance signal from said sensor;

said processor operating under control of a program stored in a memory, said processor configured to adjust the output of said source of energy by issuing control signals to said source of energy, said processor configured to apply the signal from said sensor to said program and to adjust the energy supplied to said individual's tissue by said source of energy in real time in response to the signal generated by said sensor; and

said processor configured to operate said source of energy to provide an adaptive power ramp by which a lower level of energy is initially supplied to the individual's tissue and the output of source of energy supplied to the individual's tissue is gradually increased to a higher level of energy, wherein said power ramp is provided over a predetermined interval during which impedance of the individual's tissue is monitored in real time and change in impedance over time is used to determine a slope of a next power ramp; said processor configured to adjust said power ramp during each interval of energy application based upon a rate of change in impedance over time,

for all pulses subsequent to the first, the following evaluations are made,

9. The apparatus of claim 8, wherein the source of energy is configured to apply energy to said individual's tissue at an initial energy level and increase said energy level to a terminal energy level.

10. The apparatus of claim 9, wherein the source of energy is configured to increase said energy level from said initial energy level to said terminal energy level in any of a series of discrete steps or in a continuous fashion over time.

11. The apparatus of claim 8, further comprising a processor configured to determine when a threshold impedance is reached within a specific interval, said processor configured to apply a constant, predetermined level of energy to said individual's tissue after said threshold impedance is reached and to continue application of said constant, predetermined level of energy to said individual's tissue for a predetermined interval, said processor configured to discontinue application of energy to said individual's tissue after completion of said predetermined interval.

12. The apparatus of claim 8, further comprising a processor configured to determine if said electrosurgical appliance electrodes are partially covered by the individual's tissue or are covered by thin tissue by determining if a rate of change and/or impedance threshold is reached, and thereafter apply a decreasing ramp rate and/or power cutback to prevent over-processing of the tissue.